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' <br />ANN AL FEE"and &0L /r REQUEST ci 3- 1v. <br />PERMITTEE NAME: John R. Kurtzer /OCT '15 2009 <br />PERMIT NO.: (/M-2002-053 Division c+ +Esclamafon, <br />N;ini and Safet?? <br />OPERATION NAME: Kurtzer Pit ? <br />ANNIVERSARY DATE: November 27, 2009 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Phillips <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />_ reclamation accomplished to date and during the_ preceding_year_,_new disturbances that _are_anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous vear's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: John R. Kurtzer <br />Permittee Name <br />John R. Kurtzer <br />Address: <br />24463 CR 11 <br />Haxtun, CO 80731 <br />Phone Number: (970) 774-7122 <br />Fax Number: (970) 774-3265 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />'L <br />R <br />S• ature of Corporate Officer, Owner, r Designee <br />z" <br />Date -?